Responsibilities include all the above "Core" duties/responsibilities plus the following: Provides telephonic or outpatient visits to patients at high-risk for readmissions (as identified by CM Plan) to the ER or hospital, to patients with active care planning requirements, to disease management patients per the Disease Management Plan and to others as referred via transitional care team, acute case managers and Transitional Care team. The Nurse Case Manager 1 (RN) role also involves establishing relationships with patients' families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans.